Mail Education Is as Effective as In-Class Education in Hypertensive Korean Patients

Mail Education Is as Effective as In-Class Education inHypertensive Korean Patients

Miyong T. Kim, PhD, RN1, Eun-Young Kim, PhD, RN2, Hae-Ra Han, PhD, RN1, SeongheeJeong, PhD, RN1, Jong Eun Lee, PhD, RN1, Hyun Jeong Park, MPH, CRNP, RN1, Kim B. Kim,PhD3, and Martha N. Hill, PhD, RN11Johns Hopkins University School of Nursing, Baltimore, MD2Department of Nursing, Kangwon National University, Chunchon, South Korea3Korean Resource Center, Ellicott City, MD

AbstractMany Korean American persons have hypertension, but competing life priorities often prevent themfrom attending health-promotion educational activities. Using principles of community-basedparticipatory research, the authors conducted a prospective clinical trial to determine the effectivenessof a mailed vs an in-class culturally tailored education intervention. A total of 380 hypertensiveKorean American persons from the Baltimore/Washington area were assigned to a more intense in-class education group or a less intensive mail education group. Evaluation of postintervention bloodpressure (BP) outcomes revealed that significant reductions in systolic BP (13.3 mm Hg and 16.1mm Hg, respectively) and diastolic BP (9.5 mm Hg and 10.9 mm Hg) and increases in BP controlrates (42.3% and 54.3%) were achieved in both groups. No significant differences in BP outcomesbetween groups, however, were found. In conclusion, education by mail was an effective strategyfor improving BP control and may be a viable approach for other immigrant groups if the educationmaterials address their cultural needs.

Managing chronic illnesses such as high blood pressure (BP) is a difficult task for manyAmericans,1,2 but it is even more challenging for new immigrants. Korean Americans, one ofthe most rapidly growing ethnic minority populations in the United States, have a highprevalence of high BP and its complications.3 Studies of BP in immigrant populations indicatethat, in general, the prevalence of high BP increases when a group of immigrants migrates toa more developed country4 because the stress related to acculturation and changes in diet andlifestyle may adversely affect BP levels.5–8

Previous reports have indicated that despite the high prevalence of high BP among KoreanAmerican persons, individual, cultural, and systemic barriers stand in the way of adequate BPcontrol in this population.9,10 Korean American persons experience not only uncontrolledhigh BP and its complications but also social isolation and a loss of self-confidence.11 Toaddress this health issue in Korean Americans, a community-based and culturally tailoredbehavioral intervention program, the Self-Help Intervention Program for High Blood PressureCare (SHIP-HBP), has been constructed and is currently being implemented. The SHIP-HBPincludes a comprehensive intervention trial that combines psychobehavioral education withself-monitoring of BP and bilingual nurse telephone counseling. Our primary goal in designing

© 2008 Le JacqAddress for correspondence: Miyong T. Kim, RN, PhD, Johns Hopkins University, School of Nursing, 525 North Wolfe Street, Baltimore,MD 21205-2110, [email protected].

NIH Public AccessAuthor ManuscriptJ Clin Hypertens (Greenwich). Author manuscript; available in PMC 2010 July 1.

Published in final edited form as:J Clin Hypertens (Greenwich). 2008 March ; 10(3): 176–184.

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this program was to adapt and translate evidence-based treatment guidelines and behavioralrecommendations12 into more culturally relevant education materials for first-generationKorean American persons who still subscribe to a traditional Korean culture. An equallyimportant goal was to find the most effective and feasible mode of care delivery for this targetpopulation. The focus of this paper is on the differential effects of 2 different modes of healtheducation delivery of the first component of this comprehensive intervention program,psychobehavioral education, on BP and psychosocial outcomes in a hard-to-reach middle-agedpopulation of Korean Americans. The relevance of this approach to other ethnic groups shouldbe evaluated.

While varying degrees of efficacy have been reported for structured educational interventions,13–16 the harsh reality is that competing life priorities and limited resources often prevent first-generation immigrants from attending health-promotion classes, such as BP managementclasses. For example, for many middle-aged Korean American persons, time constraints areone of the critical barriers to seeking medical help or health education programs.17 In light ofour understanding of these contextual factors and in an attempt to find the most useful waysto deliver an effective education program, we tested the effectiveness of a culturally tailoredpsychobehavioral education intervention, comparing 2 delivery modes: in-class instruction anda self-paced mail intervention.

CONCEPTUAL AND OPERATIONAL FRAMEWORK UNDERLYING THEINTERVENTION

The Learned Resourcefulness Model,18–21 in conjunction with a community-basedparticipatory research (CBPR) framework,22–25 guided the planning, implementation, andevaluation of this translational study. This model incorporates critical constructs from adultlearning, social support, and behavior modification theories.26–28 It describes how self-helpand quality of life can be affected by chronic illness, and it recognizes individual factors anddemands that affect self-care behaviors (eg, education, income, immigration status,employment status, living arrangements, and daily needs). Its theoretic premise is that if copingskills are maintained or increased through learning a self-help response to adversity, the skillssubsequently provide a stronger base for dealing with adverse situations, such as managingchronic illness.29,30

We also employed CBPR as the operational framework of this research. In particular, followingparticipatory action research principles,23,30 we solicited active community involvement in allprocesses that shaped the development of our research and intervention strategies, as well asin the implementation and evaluation. We have successfully used CBPR methodologies in ourprevious research projects involving the Korean American community, including health needsassessment,9,10,31–33 intervention development, and health service planning and development.34–36

METHODSDesign and Sample

The SHIP-HBP study is a community-based, prospective trial involving middle-aged KoreanAmerican persons in the Baltimore-Washington metropolitan area. The trial’s primaryobjective is to determine whether the SHIP-HBP is effective in controlling high BP at 3, 9, and15 months from the start of the intervention. This multifaceted intervention has 3 maincomponents: (1) a structured psychobehavioral education that focuses on fostering self-helpskills in controlling high BP, (2) home BP monitoring with a telephone transmission system,and (3) telephone counseling by a bilingual nurse who facilitates problem solving in managing

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BP. The education component was offered for 6 weeks, followed by a 6-week test period forhome BP monitoring. Home monitoring of BP and telephone counseling began 3 months afterthe start of the education intervention and lasted for 12 months. For the purposes of this paper,we used outcomes collected at 3 months, including behavioral indicators and BP outcomesmeasured before we started telephone counseling.

We used a stratified sampling scheme based on the participant’s age and sex to createcomparable groups of middle-aged Korean American persons with high BP who wererepresentative of Korean American persons who reside in the Baltimore-Washingtonmetropolitan area. Approximately 100,000 Korean American persons live in this region,37 ofwhom 23,000 are estimated to be in the target age group (40–65 years), and 41.7% are assumedto have high BP.38,39 The eligibility criteria were (1) self-identified as a first-generationKorean American, (2) 40 to 64 years of age, and (3) systolic BP (SBP) ≥140 and/or diastolicBP (DBP) ≥90 mm Hg or taking BP medication. At baseline, 445 Korean American personswere recruited primarily from ethnic Korean churches, grocery stores, and ethnic newspaperadvertisements.37 Of those completing the baseline assessment, 65 dropped out either beforethe education sessions ended or before completing follow-up data collection at 3 months ordid not measure and transmit their BP at home. The reasons for dropping out included lostcontact, travel, moving, schedule conflict, personal problem, physical condition, normal BP,belief that their BP was not high enough to require rigorous management, and overwhelmedwith assigned BP measurement. There were no significant differences in sociodemographiccharacteristics between patients who remained in the study and those who dropped out.

ProcedureOn institutional review board approval, eligible Korean Americans with high BP who agreedto participate in this study were assessed for baseline characteristics. Trained research staffmeasured BP, body weight, and height, and questionnaires were completed by self-report.Participants needed 20 to 40 minutes to complete the baseline questionnaire. They were thenassigned to either the in-class education group (n=184) or the mail education group (n=261),considering such factors as place of residence (ie, proximity to our in-class locations), schedulecompatibility (with our 21 classes in several locations at different times), and participantpreference. We were particularly careful to monitor the assignment to obtain compatible groupsas well as to minimize potential crossover effect within a relatively small social network (eg,attending the same church) between intervention groups. For example, when a group ofparticipants were identified at a church, one mode of education was offered to the churchmembers. At baseline, the in-class intervention and mail intervention groups did notsignificantly differ in terms of sociodemographic or medical characteristics. Altogether, 380participants (in-class group, 168; mailing group, 212) completed the 3-month follow-upassessments and BP measurements, and they were included in the analysis.

The mailing intervention group received weekly 2-hour in-class education sessions over 6weeks. The group intervention classes were held in a community center located in KoreanAmerican– populated neighborhoods. The self-paced mailing intervention group received thesame educational materials each week for 6 weeks via regular mail. Of those in the in-classintervention group (n=168), 86 (51.2%) attended all 6 class sessions, while the remainderattended 1 to 5 sessions (mean number of sessions attended, 5.08±1.25). During the 6-weekeducation for the in-class intervention group and on completion of the 6-week education forthe mailing intervention group, study participants were given a home-based BP measurementdevice (A&D UA-767; A&D Company, Ltd, Tokyo, Japan) equipped with a telephonetransmission system (HBPMT) and instructions. During the following 6-week testing period,participants were instructed to measure their BP at home using the device and start transmittingBP data once a week via their home telephone; this process generally took <2 minutes per

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transmission. The purpose of this test period was to increase the participants’ level ofconfidence in measuring their BP and transmitting the data and to prepare them for the next12-month telephone counseling phase, which would build on the patient’s progress in BPcontrol through tailored messages from a bilingual registered nurse.

Psychobehavioral Education InterventionOur psychobehavioral education intervention in this ongoing study has 2 main components:the first, an educational and behavioral intervention, is aimed at enhancing clients’ knowledgeof high BP and its treatment, reducing risk factors, and providing resources to Korean Americanpersons; it also focuses on improving Korean Americans’ coping/enabling skills in problemsolving, cognitive reframing, and belief in self. The second component, the psychologicalintervention, is aimed at assisting them in reframing life adversity in a different and positiveperspective. The activities of the psychosocial intervention are centered around (1) introducingand enhancing strategies for managing life adversities that are inherent in the experience ofhaving high BP and being a middle-aged immigrant, (2) providing necessary knowledge or/and information, and (3) promoting self-care behaviors related to high BP control.

MeasurementsAll study variables were measured twice (at baseline and 3 months), except for the ongoingmonitoring of BP. Research questionnaires used in this study were developed in English andtranslated into Korean, then back-translated into English. In this study, participants exclusivelyused the Korean version because they were all born in Korea and preferred using their mothertongue.

Baseline BP was measured by averaging the second and third BP readings, recorded in mmHg. Measurements of DBP and SBP were obtained by trained research assistants using theA&D UA-767, a fully automatic device based on the oscillometric method. We chose not touse mercury sphygmomanometers because of the major measurement issue of interobserverand intraobserver variability, as highlighted in 2 recently published articles.40,41 Instead, wechose the A&D UA-767 device, which had been previously validated against a mercurysphygmomanometer.42 The same device, with an additional teletransmission function, wasused for HBPMT.

Follow-up BP measurements were collected by HBPMT, measured at home with the sameA&D UA device. During this intervention trial, participants were asked to measure their BPat least 3 times in the morning and 3 times in the evening each week. For the HBPMT testperiod (6 weeks following the 6-week education intervention), self-monitoring of BP wasvalidated by automated BP reports from HBPMT, which showed the time and frequency ofBP measurements and BP readings. We used the weekly average of those transmitted data aspostintervention data.

High BP belief was measured by the high BP belief scale.43 High BP beliefs were assessed bya 12-item questionnaire, which asked participants to indicate whether they believed certainbehavioral factors could help lower BP and to select the most important factor to control BP.Higher scores represent higher levels of high BP belief. This scale has been translated intoKorean and was used in our previous study of Korean American persons with high BP,37 withan α coefficient of .897 in the present study.

Self-efficacy for high BP control was measured by a high BP management self-efficacy scale,adapted from the high BP belief scale.43 The modified scale consists of 4-point Likert-typeitems asking how confident the individual is in managing high BP in 11 areas, includingreducing salt intake, taking prescribed BP medicines, and eating fewer fatty foods. Higher

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scores represent higher levels of self-efficacy in managing high BP. The Korean version yieldedan α coefficient of .93 for the present sample.

High BP knowledge was evaluated using 12 items developed by the National High BloodPressure Education Program of the National Heart, Lung, and Blood Institute (1994), with theaddition of 18 items generated by the current investigative team on the basis of a literaturereview. This modified instrument has been used in our work with Korean American persons.9 High BP knowledge scores were calculated by counting the number of items with correctresponses to statements such as “Young adults don’t get high BP” and “High BP is life-threatening.” Scores ranged from 0 to 30.

Medication adherence was measured by the medication subscale from the Hill-BoneCompliance Scale.44 The scale consists of nine 4-point Likert-type items (1 = none of the time,2 = some of the time, 3 = most of the time, 4 = all the time) that measure the reported degreeof adherence to medication. Higher scores indicate lower adherence. This scale hasdemonstrated adequate reliability (α = .74–.84), construct validity, and predictive validity inAfrican American and non-Hispanic white patients.44 Cronbach a was .74 for the medicationsubscale in this sample.

Statistical AnalysisAnalysis was performed on 380 Korean American persons who completed both the baselineand 3-month follow-up assessments (Figure). The primary outcomes of this study were changesin SBP and DBP from baseline to 3-month follow-up. The change in the number of participantsin whom control of BP was achieved in each group (BP <140/90 mm Hg) was also assessed.Multiple data points derived from home BP monitoring were averaged at 3 months as 3-monthfollow-up data. Secondary outcomes included the level of high BP knowledge, high BP belief,self-efficacy, and the level of adherence to medication regimens. We used paired t tests toassess the differences in the proposed outcome variables between the in-class intervention andmailing intervention groups. statistical significance was determined at α=.05.

RESULTSsample Characteristics

Baseline characteristics were similar for the 380 participants, and no statistically significantdifference was observed in any of the main variables between the in-class and mail educationgroups (Table I). The mean age of the group was 52.0 years (range, 40–64 years), and close-to-equal representation of sex was attained (48.9% men, 51.1% women). Most participantswere married (94.0%) and had more than a high school education (88.4%); on average, theyhad resided in the United States for 16.2 years (Table I).

The mean duration of high BP was 4.3 years, and 73.5% of the participants reported a familyhistory of high BP. At the time of enrollment, Only 56.6% were taking BP medication. onenoteworthy characteristic of this sample was the relatively high proportion of Korean Americanpersons who had comorbidities such as kidney disease (13.1%), diabetes (11.4%), stroke(4.2%), and heart failure (1.8%). The baseline mean (SD) SBP and DBP values for the in-classeducation group were 141.5 (17.7) and 90.0 (11.1) mm Hg; those for the mail education groupwere 143.9 (17.0) and 91.8 (10.8) mm Hg.

BP OutcomesParticipants transmitted an average of 35.3 (17.3) BP readings (range, 1–93 readings) duringthe HBPMT test period (6 weeks following the 6-week education intervention). Multiple datapoints derived from HBPMT were averaged as 3-month outcome data. Three months after the

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beginning of the intervention, the average BP measurements for both groups showed dramaticimprovement (Table II). From baseline to 3 months, the mean (SD) reductions in SBP were13.3 (16.5) mm Hg in the in-class group and 16.1 (16.0) mm Hg for the mailing interventiongroup. The corresponding DBP reductions were 9.5 (10.2) mm Hg and 10.9 (10.0) mm Hg forthe in-class intervention and mailing intervention groups, respectively. During this period, thefraction of the total participants who had controlled BP (<140/90 mm Hg) more than doubledin both groups (Table III). At baseline, only 35.7% of the in-class education group and 25.9%of the mail education group had controlled BP. At 3 months of follow-up, the control rate was78.0% for the in-class education group and 80.2% for the mailing group (Table III).

Behavioral OutcomesIn general, the psychological and behavioral outcomes improved to a similar degree in the twogroups. Data at 3-month follow-up, including those regarding feelings of self-efficacy and highBP knowledge, health belief, and medication adherence were significantly improved whencompared with baseline measurements for both groups (Table IV).

DISCUSSIONThe results from the 3-month assessment in this ongoing study have indicated that culturallytailored interventions can greatly improve BP control in middle-aged Korean Americanpersons. In particular, our findings suggest that applying a community-partnered approach todeveloping culturally sensitive intervention materials and executing the trial in a traditionallyunderstudied minority community may be an important and effective operational strategy forcomplex behavioral intervention involving immigrants with high BP.

In particular, the CBPR approach was useful in crafting intervention messages that directlyaddress beliefs, attitudes, and knowledge that are closely embedded in Korean Americanpersons’ cultural upbringing. For example, through our formative intervention phase, ourcommunity-partnered intervention team found that one of the major barriers to taking high BPmedication among Korean Americans with high BP was the myth that BP medication can betoxic or even addictive. Many expressed concerns such as “I heard that once you got onmedication, you have to be on it for the rest of your life,” or “One needs to postpone takingmedication as long as one can in order to prevent organ damage.” To address these prevalentmyths, the education materials focused on the fact that the harmful effects on target organs ofdelaying BP treatment far outweigh any possible adverse effects of high BP medication. Inaddition, our team chose several intervention messages that addressed myths rooted in culturalbeliefs and repeatedly incorporated these messages into written education materials as well asthe telephone counseling protocol. Throughout the process, cultural knowledge of and insightsinto the target ethnic community that were provided by the community members of our researchteam were essential in crafting and delivering culturally and contextually relevant interventionmaterials. Such a CBPR approach has been adopted by increasing numbers of researchers indesigning effective interventions aimed at complex behavioral changes, such as managingchronic illness.45,46

Our results also suggest that for the delivery of an initial education intervention, a self-pacingmail intervention was as effective as in-class education in terms of achieving an optimal BPlevel. The changes in secondary outcomes in the mail intervention group, however, such as thelevel of high BP knowledge and adherence to BP medication, were not as great as those in thein-class education group. It is not yet certain whether the revealed group difference is aclinically meaningful one. While these differences do not suggest that there are significantbarriers to achieving and maintaining optimal BP after in-class or in-mail education, the long-term maintenance of the obtained intervention effects will be evaluated as this study progresses.

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Several potential limitations should be borne in mind when interpreting our findings. First, ourstudy is not designed to distinguish the precise intervention effects of each component (ie,education, monitoring). While both groups received the same amount of education and wereadvised to self-monitor their BP, it is possible that the differential effect of the interventiondelivery methods (mail vs in-class education) might be replicable only with implementationof other intervention components. Second, we were unable to use traditional random samplingbecause of the potential crossover effect that can occur in a close-knit ethnic community.Although there were no significant differences in the major characteristics of each group thatwould be expected to prevent us from successfully creating comparable conditions in the groupassignments, it is possible that some as yet unidentified influence could have affected the studyoutcome. Third, our study may suffer from some of the inherent validity limitations associatedwith the main data gathering method, self-report, or some key demographic variable such asincome level. The method of a self-report was chosen to accommodate the need forconfidentiality among the Korean American persons who were not exposed to many researchprojects. Finally, we did not have specific medication data at 3 months; it is possible that somepatients had medication changes during this time period that might have changed the results.

In addition, it is difficult to compare findings regarding the effects of the mail intervention inthe present study with those in the existing literature because of a lack of published reportsregarding the use of self-pacing mail interventions in chronic illness management in acommunity setting. Mail intervention has predominantly been used either to deliver a simplehealth message, such as how to detect the signs of heart attack or stroke,47,48 or to urge peopleto act, such as to making an appointment or to remembering to get a follow-up checkup.49,50

The present study is the first structured trial to evaluate the effectiveness and practical utilityof a self-paced mail education intervention related to the rather complex subject of managinghigh BP. If these findings can be replicated in other studies, they may have significant clinicalimplications. A lack of time is one of the most critical barriers for implementing intenseeducational interventions in middle-aged patients, regardless of ethnic background, and a self-paced mail education intervention offers an alternative strategy that can reach many patientswho are in need of proper education in managing their chronic illness.

CONCLUSIONWe have shown that a community-based intervention, culturally tailored to address the culturalupbringing and contextual factors in the lifestyle of the target population, can have a positiveimpact on improving the health and quality of life of many individuals. As the findings of arecent national hypertension management survey highlighted, misconceptions about the natureand management of hypertension persist in all levels of society, including ethnic minoritypopulations.51 The method used in this study may potentially be translatable and usable byclinicians and researchers who are working to improve the health and quality of life ofunderserved and vulnerable populations.

AcknowledgmentsDisclosure: This research is supported by the Agency for Health Care Research and Quality (HS013160) and in partby the Center for Collaborative Intervention Research at the Johns Hopkins University (P30 NR008995).

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50. McFarland LV, Reiber GE, Norman JE. Recruitment of Medicaid and dual-enrolled Medicarebeneficiaries with diabetes mellitus into a randomized controlled trial. Am J Manag Care 2005;11(7):443–448. [PubMed: 16044981]

51. Moser M, Franklin SS. Hypertension management: results of a new national survey for thehypertension education foundation: Harris interactive. J Clin Hypertens (Greenwich) 2007;9:316–323. [PubMed: 17485966]

Kim et al. Page 10


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Figure 1.Participant tracking.

Kim et al. Page 11


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Kim et al. Page 12

Table I

Demographics of Enrolled Participants at Baseline

VARIABLES IN-CLASS (N=168) MAILING (N=212) TOTAL (N=380) χ2/T (P VALUE)

Age, y

40–49 59 (35.1) 78 (36.8) 137 (36.1) 5.250 (.073)

50–59 93 (55.4) 126 (59.4) 219 (57.6)

60–64 16 (9.5) 8 (3.8) 24 (6.3)

Mean (SD) 52.3 (5.8) 51.7 (5.6) 52.0 (5.7) 1.027 (.311)

Sex

Male 86 (51.2) 100 (47.2) 186 (48.9) 0.606 (.436)

Female 82 (48.8) 112 (52.8) 194 (51.1)

Marital status

Married 155 (92.3) 202 (95.3) 357 (94.0) 1.504 (.220)

Other 13 (7.7) 10 (4.7) 23 (6.1)

Education

Less than high school 20 (11.9) 24 (11.3) 44 (11.6) 0.077 (.962)

High school graduate 56 (33.3) 69 (32.6) 125 (32.9)

≥Some college 92 (54.8) 119 (56.1) 211 (55.5)

Work status

Full-time 116 (69.1) 153 (72.5) 270 (71.1) 2.810 (.422)

Part-time 24 (14.3) 19 (9.0) 43 (11.4)

No job 18 (10.7) 27 (12.8) 45 (11.9)

Other 10 (5.9) 12 (5.7) 22 (5.8)

Income level

Very comfortable/comfortable 56 (33.5) 74 (35.4) 130 (34.6) 1.171 (.557)

“Okay” 62 (37.1) 84 (40.2) 146 (38.8)

Difficult/very difficult to manage 49 (29.3) 51 (24.4) 100 (26.6)

Years of residence in the United States, mean (SD)

17.2 (8.9) 15.3 (9.0) 16.2 (9.0) 1.911 (.057)

Body mass index, kg/m2

<25 (normal) 78 (46.4) 115 (54.3) 194 (50.8) 2.330 (.312)

25–30 (overweight) 78 (46.4) 85 (40.1) 163 (42.9)

≥30 (obese) 12 (7.1) 12 (5.7) 24 (6.3)

Taking BP medication

Yes 97 (58.3) 117 (55.2) 215 (56.6) 0.377 (.539)

No 70 (41.7) 95 (44.8) 165 (43.4)

Relevant disease

Heart failure 5 (3.0) 2 (0.9) 7 (1.8) 2.142 (.143)

Myocardial infarction 5 (3.0) 3 (1.4) 8 (2.1) 1.127 (.288)

Stroke 11 (6.6) 5 (2.4) 16 (4.2) 5.264 (.072)

Kidney disease 19 (11.4) 31 (14.5) 50 (13.1) 4.796 (.091)

Diabetes 24 (14.4) 19 (9.0) 43 (11.4) 3.532 (.171)

Family history of high BP


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Kim et al. Page 13

VARIABLES IN-CLASS (N=168) MAILING (N=212) TOTAL (N=380) χ2/T (P VALUE)

Yes 122 (72.6) 156 (73.9) 278 (73.5) 1.554 (.460)

Years of high BP, mean (SD) 4.1 (5.8) 4.4 (6.5) 4.3 (6.2) −0.585 (.559)

Values are expressed as No. (%) unless otherwise indicated.

Abbreviation: BP, blood pressure.


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Kim et al. Page 14

Tabl

e II

Blo

od P

ress

ure

Bef

ore

and

Afte

r Edu

catio

n In

terv

entio

n

BA

SEL

INE

POST

INT

ER

VE

NT

ION

CH

AN

GE

T V

AL

UE

P V

AL

UE

Syst

olic

blo

od p

ress

ure,

mm

Hg

In-

clas

s (n=

168)

141.

5 (1

7.7)

128.

2 (1

2.9)

−13.

3 (1

6.5)

−10.

49.0

00

Mai

ling

(n=2

12)

143.

9 (1

7.0)

127.

8 (1

2.8)

−16.

1 (1

6.0)

−14.

64.0

00

Tot

al (N

=380

)14

2.9

(17.

3)12

8.0

(12.

8)−1

4.9

(16.

2)−1

7.84

.000

Dia

stol

ic b

lood

pre

ssur

e, m

m H

g

In-

clas

s (n=

168)

90.0

(11.

1)81

.4 (8

.5)

−9.5

(10.

2)−1

2.07

.000

Mai

ling

(n=2

12)

91.8

(10.

8)80

.9 (9

.0)

−10.

9 (1

0.0)

−16.

03.0

00

Tot

al (N

=380

)91

.91.

4 (1

1.0)

81.1

(8.8

)−1

0.3

(10.

1)−1

9.95

.000

Val

ues a

re m

ean

(SD

).


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Kim et al. Page 15

Table III

Blood Pressure Control Rates Before and After Educational Intervention

BASELINE POSTINTERVENTION χ2 (P VALUE)

Class (n=168) 60 (35.7) 131 (78.0) 7.857 (.005)

Mailing (n=212) 55 (25.9) 170 (80.2)

Total (N=380) 115 (30.3) 301 (79.2)

Blood pressure control defined as <140/90 mm Hg. Values are expressed as No. (%).


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Kim et al. Page 16

Tabl

e IV

Psyc

hoso

cial

Cor

rela

tes o

f Blo

od P

ress

ure

Con

trol a

t Bas

elin

e an

d A

fter E

duca

tiona

l Int

erve

ntio

n (N

=380

)

BA

SEL

INE

POST

INT

ER

VE

NT

ION

CH

AN

GE

T V

AL

UE

P V

AL

UE

Self-

effic

acy

(1.0

to ≈

4.0)

, mea

n (S

D)

In-

clas

s (n=

168)

3.07

(0.4

3)3.

24 (0

.36)

0.17

(0.3

8)5.

58.0

00

Mai

ling

(n=2

10)

3.05

(0.3

8)3.

20 (0

.37)

0.15

(0.3

4)6.

50.0

00

Kno

wle

dge

of h

igh

bloo

d pr

essu

re (0

.0 to

≈26

.0),

mea

n (S

D)

In-

clas

s (n=

168)

18.8

0 (3

.85)

22.9

1 (2

.48)

4.11

(4.0

1)13

.26

.000

Mai

ling

(n=2

12)

18.9

3 (4

.30)

21.5

8 (3

.28)

2.64

(3.7

1)10

.36

.000

Hea

lth b

elie

fs (1

.0 to

≈5.

0), m

ean

(SD

)

In-

clas

s (n=

165)

4.72

(0.4

1)4.

83 (0

.29)

0.11

(0.3

8)3.

83.0

00

Mai

ling

(n=2

12)

4.67

(0.4

6)4.

75 (0

.29)

0.09

(0.4

2)3.

11.0

02

Med

icat

ion

adhe

renc

e (1

.0 to

≈4.

0), m

ean

(SD

)a

In-

clas

s (n=

98)

3.41

(0.3

3)3.

49 (0

.28)

0.08

(0.2

7)2.

76.0

07

Mai

ling

(n=1

17)

3.37

(0.3

7)3.

46 (0

.28)

0.09

(0.3

5)2.

91.0

04

a Ana

lyze

d fo

r 215

par

ticip

ants

who

wer

e ta

king

ant

ihyp

erte

nsiv

e m

edic

atio

n.


Mail Education Is as Effective as In-Class Education in Hypertensive Korean Patients

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